Mammography vs. Ductal Lavage: An Interview with Susan Love, M.D.

Susan Love, M.D., is an adjunct professor of Surgery at UCLA and the medical director of the Susan Love MD Breast Cancer Foundation, a nonprofit organization dedicated to the eradication of breast cancer. She is the author of "Dr. Susan Love's Breast Book" and "Dr. Susan Love's Hormone Book."

What are the limitations of mammography?

The problem is that mammography is not perfect. We would love it to be perfect, but what it does is take a picture of the breast. It looks at shadows, and depending on how dense your breast tissue is it can see through it better or worse. In some women their tissue is so dense that it misses the cancers. It is like looking for a polar bear in the snow; you just can't see it.

In other people their cancers are so aggressive that they have already spread even by the time you can see it on a mammogram. And in some people their cancers are so slow that you are not going to find them. Now mammography in women over fifty will change their survival by thirty percent. That is a lot but it is not a hundred percent. And in the other seventy percent it is not really making much of a difference.

It is the best tool we have. I think women should be getting it, but we also should be working as hard as we can to get something better, something that really will work in not just thirty percent but eighty, ninety, a hundred percent.

In comparison to mammography, what are the benefits of ductal lavage?

The problem with mammography is that by the time you can see a lump or feel it it has been there eight to ten years, so what we call early detection is really only slightly earlier detection, it is not early detection.

What we really need to do is get much, much earlier in the process, not finding cancers but finding cells that are just thinking about being cancer someday so that we can head them off at the pass and never get the cancer.

All breast cancer starts in the lining of the milk ducts—all of it — so if we could get to the lining of the milk ducts we have the opportunity to find cells early in the process of developing cancer, before they are cancer, and maybe do something to reverse it.

And ductal lavage is a way to do that. It is a tiny catheter that you can thread into the milk duct, squirt in some salt water, wash out the cells and look at them under a microscope and see what they are doing. Sort of the way we do with a Pap smear.

What made you think of ductal lavage?

Well, it kept bothering me that we were so late in the process and that breast cancer really started in the milk ducts. Milk came out in one direction, so why couldn't we go in in the other direction? I was amazed to see that there was so little research on the milk ducts. Nobody knew about the anatomy of the ducts, nobody knew how many holes there were in the nipple.

I took a research assistant and we went to a meeting of breast-feeding women and counted the holes and mapped the holes in the nipple because that is when you could see them. But nobody had done that before. So really we had been thinking about the breast as a whole organ rather than a collection of ductal systems. When you start to realize that only one ductal system gets cancer then it changes the way you approach the disease.

How do you mean one ductal system?

When you get breast cancer you only get it in one ductal system, not in the whole breast. . . . And my hope is that with ductal lavage we will go into the next level and be able to just squirt something down that ductal system and clean it out and never get to surgery and radiation and chemotherapy.

So when you did it for the first time you put salt water down and you got at these cells, what was it like? Did you suddenly find that you could see precancerous cells?

Well, we first started looking down the duct with a scope, actually, about ten years ago. You could look down the duct but it was easy to get lost because it actually has a lot of branches, sort of like a root. And then I decided, well, washing out the duct might be better, and I looked back and found out that I wasn't the first one to think of this.

We always think that we have these wonderful ideas but actually the first person to think of it was a guy in Uruguay in the 1940's who did something he called ductal rinse and squirted some fluid down the ducts and got cells back. And then George Papanicolaou in the 1950s squeezed the nipple and got the little cells back. And somebody else in the 70s tried it, so I realized that one, it was doable and two, that I wasn't the first one to think of it.

But the tricky part was getting the catheter just right so that we actually could squirt the fluid in and get it back again. The ducts are very expandable. When you breast-feed they suddenly get bigger and can take a lot more milk. So when you put the salt water in they expand and you want to be able to get the salt water back out again. So devising the whole procedure took a number of years.

For whom should ductal lavage be used?

At the moment I think ductal lavage is best in women who are at high risk for breast cancer or have breast cancer in one breast and want to monitor the other breast.

Note: Ductal lavage is currently used for assessing risk of breast cancer. For more information on its availability in your area, visit ductallavage.com.

The usefulness of ductal lavage for early breast cancer detection is still under study. For more on clinical trials, go to www.clinicaltrials.gov, which includes information on clinical trials supported by the Federal government.